Three Part Question

In [overdose with tricyclic antidepressants] does [the addition of glucagon to standard treatments] improve [clinical outcome]?

Clinical Scenario

A 27 year old woman attends the emergency department with a suspected amitriptyline overdose. She has a Glasgow Coma Score of 7, is trypsilating, and has a broad complex tachycardia and a blood pressure of 70/30. After intubation and ventilation and sodium bicarbonate she remains tachycardic at 130 although her complexes have narrowed somewhat and her BP is still low at 80/40. You have heard that tricyclic overdoses may respond to glucagon and wonder whether there is any evidence for this.

Search Strategy

Medline 1966-02/03 using the OVID interface.
[(exp antidepressive agents OR exp antidepressive agents, tricyclic OR exp desipramine OR exp amitriptyline OR tricyc$.af OR amitriptyline.af OR amoxapine.af OR clomipramine.af OR doxepin.af OR dothiepin.af OR imipramine.af OR lofepramine.af OR nortriptyline.af OR trimipramine.af) AND (exp glucagon OR glucagon.af)] Limit to human AND English.

Comment(s)

Although all 3 patients received multiple treatments the authors state the improvement in condition was immediately after high dose glucagon administration. TNo reports of failure to response to glucagon are found in the literature. This is most probably attributable to reporting bias. Further research is required.

Clinical Bottom Line

There is not enough evidence currently available to support the use of glucagon in tricyclic overdose.

References

Ruddy JM, Seymour JL, Anderson NG. Management of tricyclic antidepressant ingestion in children with special reference to the use of glucagon. Medical Journal of Australia 1972;1(13):630-3.